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Nutirtional Support in
  Surgical patients
      Dept of Thoracic and
  cardiovascular surgery, SNUH
        MD. Kim Jun Sung
         Key points in nutrition
   Selection the correct route for nutritional
    support
   Parenteral nutrition should be used only in
    patients with intestinal failure who are unable
    to meet their nutritional needs via the GI tract
   Parenteral nutrition should be supervised by a
    multidisciplinary support team

* Malnutrition is common, with a 40%
  prevalence on admission to hospital, while in
  hospital 78% of all patients lost weight during
  their stay
Metabolic response in the surgical
             patient

   Modulated by changes in the
    neuroendocrine milieu.

   Increasement : catecholamine,
    glucocorticoids, glucagone, GH,
    aldosterone, ADH.
Metabolic response in the surgical
             patient
   Cortisol : amino-acids of skeletal muscle to
    substrate for wound healing ( negative
    nitrogen balance )
   Catecholamine : increase the basal metabolic
    rate
   Aldosterone and ADH : impair of water
    excretion, weight gain secondary to sodium
    and water retention.
   Counter-regulatory hormone : stress DM
    (hyperglycemia)
Metabolic response in complications
    in the postoperative period
                                CYTOKINES


  Interluken-1                         Inteluken-6

                                       Production of acute phase
  Fever
                                       protein for wound healing
  Anorexia
                                       Antimicrobial function
  Increase in blood leukocyte
                                       Mobilizaqtion of substrate
  counts
                                       stores
  Hypoalbuminemia
                                       Adverse effects in
  Redistribution of trace              malnourished patients
  minerals
Metabolic response in complications
    in the postoperative period
    Primary mediators that control the
     stress response include TNF and
     interleukin-1

    TNF : one of the catabolic mediators in
     stress-related protein metabolism,
     induces cachexia in the hypermetabolic
     patient, resulting in an increase in
     resting energy expenditure
    The Goals of Nutritional support
   To identify high risk patient for
    malnutrition

   To design an appropriate program to
    meet the needs

   To prevent and treat the macro- and
    micronutrient deficiency
       Nutritional Assessment
   Percentage of BWt loss in the previous
    6months
     - mild (<5%), moderate (5~10%),
    severe (>10%)
   S-albumin : hypoalbuminemia in ill
    patient by down regulation(IL-1,TNF),
    catabolism and shift to extravascular
    space ( -> excellent marker for injury
    response, not nutritional marker)
       Nutritional Assessment
   Pre-albumin : malnutrition marker (may
    be affected by cytokine in severe
    infection)
   Immune competence (delayed
    hypersensitivity) : malnutrition marker
    (may be altered by many factors)

There is no criterion standard for evaluating
nutritional status…
Preoperative Nutrition Support
   Klein and colleague (1997)…
    preoperative TPN for malnourished patients
    decreased postoperative complication by
    10%(no difference in the mortality)
   VA multi-institutional trial (1991)…
    more infectious Cx in the preop TPN group,
    fewer non-septic Cx in the preop TPN group

* There was no benefit from routine use of preop
  TPN in mild or moderate degree malnutrition
  patients
Postoperative parenteral nutritional
             support
   The effect of postoperative TPN on surgical outcome
    (meta-analysis)
    - increased Cx by 10% with no differences in the
    mortality
   Sandstorm et al, higher Cx rate in prolonged NPO
    (>14days)
    * Consensus conference of NIH,ASCN,ASPEN…

- Postoperative nutrition support must be administered
  to the patients who are not expected to resume an
  oral diet for 7 to 10 days.
- Routine use of postoperative TPN is not
  recommended and may increase septic complication
    Postoperative Enteral Nutritional
                Support
   Mucosal atrophy occurs in the absence of
    enteral nutrition during bowel rest or
    starvation
   Factors that favor bacterial translocation
    include physical disruption of the gut mucosa
    because of endotoxin, parenteral nutrition or
    bowel rest, impaired host immune responses,
    and disruption of the normal gut microflora
    that results in bacterial overgrowth
    Postoperative Enteral Nutritional
                Support
   fewer total complications , less
    infectious complications, a reduction in
    hospital stay
    (Beier Holgerson R, Boseby S , Gut 1996; 39:833–835)

   initiation of enteral tube feedings may
    beneficially modify the injury response
    and should be considered in the
    nutritional management of postoperative
    patients if feasible
    Enteral Vs Parenteral Nutritional
                Support
   enteral nutrition when tolerated is the
    preferred route of nutritional support.
    - physiological, cheaper, and few metabolic
    disturbances (ie, hyperglycemia, cholestasis,
    and fatty infiltration of the liver).
   parenteral nutrition support should probably
    be considered in the postoperative patients
    with a higher risk for nutritional complications
    who cannot be adequately nourished by the
    enteral route,
General principles to help avoid
   catheter-related sepsis
   Designing a
Nutritional Program
              TOTAL CALORIES
   To estimate basal energy expenditure
    (BEE)
     men BEE = 66.5 + 5.0 (height in cm) + 13.8 (weight
    in kg) – 6.8 (age in years)
     women BEE = 65.5 + 1.9 (height in cm) + 9.6
    (weight in kg) – 4.7 (age in years).


   Most patients can be adequately fed at 100~120% of
    the BEE
             TOTAL CALORIES
    1일 열량요구량 = BEE X activity index X stress index

       Activity index              Stress index
Paralyzed           1.0     Mild starvation         0.9
Bed rest            1.1     Postoperative(simple)   1.0
Ambulation          1.2     Peritonitis             1.2
Normal activity     1.5     Long bone infection     1.3
Hyperactivity       2.0     Severeinfection          1.4
                            Multiple trauma         1.4
                            Burn (>40%)              2.0
     Fluid Requirements


100 ml/kg for each of the 1st 10kg+


50 ml/kg for each of the next 10kg+


20 ml/kg for each kg>20kg
     Electrolyte requirements

Electrolyte      Maintenance
Na+              2~4mEq/kg/day
K+               2~3mEq/kg/day
Cl-              2~4mEq/kg/day
Ca++             1~3mEq/kg/day
Mg++             30~60mg/kg/day
PO3              1~2mmol/kg/day
Equations for Predicting Resting
 Energy Expenditure (pediatric)

          Age (yrs)    kcal/day
Males       0~3       60.9W-54
            3~10      22.7W+495
           10~18      17.5W+651
Females     0~3       61W-51
            3~10      22.5W+499
            10~18     12.2W+746
                       (W: weight in kg)
               Energy Needs
   the combination of resting energy expenditure,
    activity, rate of growth, diet-induced
    thermogenesis, fecal loses, and maintenance
    of body temperature

   Stress and/or injury factors can increase
    energy requirements by approximately 30%
    for mild to moderate stress, 50% in severe
    stress, and 100% in major burns

   neuromuscular paralysis and sedation may
    decrease energy needs in critical illness by as
    much as 30%.
                 GLUCOSE
   The optimal proportion of the glucose
    calories should be 50–70% of the total
    caloric intake

   should be adjusted to maintain a blood
    glucose level less than 200 mg/dl,
    including administering regular insulin if
    necessary
                 PROTEIN
   15–20% can be given as protein or
    amino acids

   In general, stressed patients with
    normal hepatic and renal function
    should receive approximately 1.5 g of
    protein per kilogram of body weight per
    day
                    FAT
   a good energy source during the
    postoperative period because of its high
    caloric value

   Parenteral administration of lipids
    should be limited to approximately 30%
    of the total calories and provided as a
    continuous infusion
Nutrition support techniques
Peripheral Vein Versus Central Venous
                Access

    Maximum dextrose concentration for
     peripheral PN solution is 12.5%
     dextrose

    the maximum osmolarity should not
     exceed 900 mOsm/L in peripheral PN
      For enteral feeding (SFD)
   Most formulas : approximately 1,000 kcal, 40
    g of protein, 40 mEq of sodium, and 40 mEq
    of potassium per liter of solution
   begin with a rate of 20 mls/h and to increase
    the rate by 10 ml/h increments every 12 to 24
    hours to the goal rate
   The daily water requirement should be
    determined for each patient and would
    depend upon the fluid status
      Monitoring After Initiation of
          Nutritional Support
   monitoring of weight, fluid, and acid-
    base balance, plasma glucose, and
    electrolytes

   The level of serum albumin does not
    reflect acute nutritional changes despite
    being widely used as a preoperative
    marker of nutritional status.
     Nutrient
Recommendations for
   Wound Healing
           The healing process
   first stage, inflammation (4 to 6 days) : The
    macrophage, the predominant immune cell, clears
    necrotic tissue and bacteria and secretes GF.

   second stage, proliferation (2weeks) : repair the
    damage (e.g., fibroblasts) and begin the formation of
    granular tissue and epithelium.

   third stage, maturation (~2years) : signals the end of
    the healing process. characterized by collagen
    stabilization (the tensile strength of the wound)
     recommendations promoting
          wound healing
    Provide a balanced diet or nutrition support
    Provide sufficient protein to achieve
    positive nitrogen balance
    Treat suspected micronutrient deficiencies,
    especially vitamin A, vitamin C, and zinc;
    Prevent nutrient toxicity
    Maintain fluid balance
    Treat conditions that limit blood flow to the
    wounded tissues
 Vitamin   A, C, E

     Protein



 Arginine,   zinc

     Water
                   Vitamin A
   as an immunostimulant
   antagonizes steroid-induced delays in wound
    healing

   Perioperative 25,000 to 50,000 IU per day
    orally and 10,000 IU IV for severely to
    moderately injured patients or for
    malnourished patients.
   potentially toxic in hepatic and renal failure
               VITAMIN C
   increasing collagen synthesis,
    neutrophil function, and angiogenesis

   1000 to 2000 mg/day for wounded
    patients

   No adverse effect
                 VITAMIN E
   as an antioxidant , anti-inflammatory
    properties like those of steroids, inhibits
    collagen synthesis, and decreases
    tensile strength of wounds

   wounded adult patients should receive
    the current RDA of 15 mg/day
                    ZINC
   essential trace mineral that is required
    for cellular growth and replication

   50 mg elemental zinc (220 mg zinc
    sulfate) given orally up to three times
    per day are used in injured patients
   2.5 to 4 mg zinc/day for stable patients
    receiving TPN and 4.5 to 6.0 mg
    zinc/day for severely catabolic patients
                PROTEIN
   structural components for the skin and
    are required for growth and
    maintenance of cells and for fluid and
    electrolyte balance

   for healthy adults : 0.8 g/kg
   for wound healing :1.25 to 1.5 g/kg
                ARGININE
   secretion of the anabolic hormones
    insulin and growth hormone
   can be catabolized by immune cells to
    nitric oxide or ornithine

   17 to 24.8 g of free arginine per day (1L
    of 10% amino acid -approximately 12 g
    of arginine)
                  WATER
   a significant portion of the blood and
    hydrates the skin

   The average adult needs between 2000
    to 3000 ml of fluid per day to replace
    losses from urine, stool, exhalation, and
    the skin
   Metabolic and
nutritional support in
acute cardiac failure
             Cardiac cachexia
   caused both by a decrease in nutrient intake
    as a result of anorexia and malabsorption,
    and by specific metabolic alterations
    observed in the critically ill patient, such as
    hypermetabolism and hypercatabolism and
    the acute phase response.

   unintentional weight loss of more than 7.5%
    of the previous normal weight has been
    shown to be an independent risk factor for
    mortality in chronic heart failure
      Mechanisms of Malnutrition
           in Heart Failure
   Hypercatabolism :
    activation of catabolic factors, such as
    norepinephrine ,epinephrine, cortisol ,
    inflammatory cytokines, hyperinsulinism
    and insulinoresistance

   Nutrient Intestinal Malabsorption
   Anorexia
      Anabolic and Anticatabolic
              Treatment
   hormonal anabolic agents such as GH
    or prasterone may enhance protein
    synthesis and thus improve both
    cardiac function and muscle mass
   Balanced protein supplementation
   Anticytokine therapy with various
    phosphodiesterase (PDE) inhibitors,
    ACE inhibitors , [beta]-blocker
   Antioxidant therapy with Vitamin E
                Salt Intake


   reducing water and sodium retention

   the daily salt allowance should be
    between 2 and 4g
        Thiamine Deficiency in
     Furosemide-Treated Patients
   an inappropriate urinary thiamine loss
    caused by loop diuretics

   the adverse cardiovascular effect of
    thiamine deficiency known as ‘wet
    beriberi’, i.e. sodium and water
    retention, peripheral vasodilatation, and
    biventricular myocardial failure
     Nutritional Support in Surgical
            Patients with CHF



   a daily caloric load of 20 to 30
    kCal/kg/joule or 2000 kCal/day and a
    nitrogen intake of 15 g/day
Metabolic and nutritional support
Glucose-insulin-potassium infusion
   1962, Sodi-Pallares et al. improved the
    outcome after myocardial infarction and
    reduced ventricular arrhythmias by GIK
   metabolic effects, direct hemodynamic
    effects, improvements of coronary flow,
    and catecholamine mediated effects
   tight glycemic control is a determinant
    of outcome
   Until now the clinical results :
    controversial
   Glucose-insulin-potassium solutions enhance
recovery after urgent coronary artery bypass grafting
         J Thorac Cardiovasc Surg 1997;113:354–60


    Lazar, Harold L. MD; Philippides, George MD;
     The Boston University Medical Center

     Patients treated with GIK had
     - higher cardiac indices
     - lower inotrope scores
     - less weight gain
     - shorter times of ventilator support
     - a significantly lower incidence of atrial
      fibrillation
     - shorter stays in the ICU and hospital
 Nutrition in chronic
obstructive pulmonary
        disease
    Rationale for nutritional support
   By the 1960s, several studies had
    already reported that a low body weight
    and weight loss are negatively
    associated with survival in patients with
    COPD
   weight gain after nutritional support has
    been associated with decreased
    mortality
Causes of weight loss and muscle
            wasting

   elevated REE was found in COPD
    (breathing work, drug therapy, and
    systemic inflammation)

   Dietary intake deceased
Outcome of nutritional intervention

    Anabolic agents : recombinant human
     growth hormone (rhGH), steroid- more
     studies are needed

    Anticatabolic agents
Therapeutic Diet in
      SNUH
                   일반식이

영양소       열량      탄수화물(g)   단백질     지방      소금
(1일)     (kcal)              (g)    (g)     (g)

NRD/TD   2100       345       80      45    15~20
                   (65%)    (15%)   (20%)

 SBD     1600       200       80      55
                   (50%)    (20%)   (30%)

 SFD     1200       165       39      44
                   (54%)    (13%)   (33%)
                    위절제후식
   고단백, 고열량식, 소량으로 자주


    영양소     열량      탄수화물    단백질     지방      수분량
    (1일)   (kcal)    (g)     (g)    (g)      (cc)

    위절제    430        95     10       1     1150
    유동식             (89%)   (9%)    (2%)
    위절제    2150      280     100      70    1500
    연식              (52%)   (19%)   (29%)
    위절제    2250      300     100      70    2000
    상식              (54%)   (18%)   (28%)
                     심장질환식이

영양소          열량      탄수화물    단백질     지방      콜레스테     나트륨
(1일)        (kcal)    (g)     (g)    (g)       롤      (mg)
                                              (mg)
고지혈증        1500      225      75      35    150~     2000~
 식                   (60%)   (20%)   (20%)    200      6000
(50kg 기준)                                            (소금 5~15g)

심혈관계        1200      195      60      20    <200      2000
중환자식                 (65%)   (20%)   (15%)            (소금5g)
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